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R'A <br /> REPUBLIC' NON-HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST <br /> 4*4 SERVICES RECEIVED <br /> `� ! � 't If waste is asbestos waste,complete Sections I,Il,III and IV <br /> If waste is NOT asbestos waste,complete Sections I,11 and III <br /> 1. <br /> GENERATOR (Generator completes la-r) MAY 3 1 2019 <br /> a.Generator's US EPA ID Number b_Manifest Document Number L N f fM i f N_FA L I I F:k L,I I <br /> d.Generator's Name and Location: e.Generator's Mailing Address: <br /> .443Arnir,ee <br /> ry Um, <br /> f.Phone: StX,*►r CA 66' g.Phone: <br /> If owner of the generating facilitydiffers from the generator,provide: <br /> h.Owner's Name: i.Owner's Phone No.: <br /> j.Waste Profile# k.Exp.Date I.Waste Shipping Name and m.Containers n.Total o.Unit <br /> Description No. T e Quantity Wt/Vol <br /> I <br /> GENERATOR'S CERTIFICATION: I hereby ceruiy that the above named material is not a hazardous waste as defined by 40 CFR 261 or any applicable <br /> state law,has been properly described,classified and packaged,and is in proper condition for transportation according to applicable regulations:AND,if this <br /> waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Restrictions. I certify and warrant that the waste has <br /> been treated in acro:iiance with the requirements of 40 CFR and is no longer a hazardous waste as defined by 40 CFR 261. <br /> �.Generator Authorized Agent Name(Print) q.Signature _ r.Date <br /> II. _TRANSPORTER (Generator completes Ila-b and Transporter completes Ilc-e) <br /> a.Transporter's Name and Address: <br /> b.Phone: <br /> c.Driver Name((Print) d.Signature I e.Date <br /> III. DESTINATION (Generator complete Illa-c and Destination Site completes Illd-g) <br /> a.Disposal Facility and Site Address: c.US EPA Number d.Discrepancy Indication Space: <br /> S Am'a; <br /> 1 hereby certify that the above named material has been acce ted and to the best of my knowledge the foregoing is true and accurate. <br /> I <br /> e.Name of Authorized Agent Print f-Signature Date <br /> IV. ASBESTOS (Generator completes IVa-f and Operator complete IVg-i) <br /> a.Operator's Name and Address: c.Responsible Agency Name and Address: <br /> b- Phone: d.Phone: <br /> e.Special Handling Instructions and Additional Information: <br /> f.❑ Friable ❑ Non-Friable ❑ Both %Friable %Non-Friable <br /> OPERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name <br /> and are classified,packaged,marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and <br /> national governmental regulations. <br /> q.Operator's Name and Title Print h.Signature i.Date <br /> "Operator refers to the company which owns,leases,operates,controls,or supervises the facility being demolished or renovated,or the demolition or <br /> renovation operation or both <br /> REV 01/14 RETURN TO OPERATOR RS-F11A <br />